Of proxies and POLSTs: The good and the bad in end-of-life planning

Fr. Tadeusz Pacholczyk

Planning for end-of-life situations is important. We should put in place an advance directive before our health takes a serious turn for the worse and we are no longer able to indicate our own wishes or make our own decisions. Advance directives can be of two types: living wills and health care agents.

The best approach is to choose a health care agent (a.k.a. a “proxy” or a “durable power of attorney for health care”). Our agent then makes decisions on our behalf when we become incapacitated. We should designate in writing who our health care proxy will be. The National Catholic Bioethics Center (www.ncbcenter.org) and many individual state Catholic conferences offer helpful forms that can be used to designate our proxy. Copies of our completed health care proxy designation forms should be shared with our proxy, our doctors, nurse practitioners, hospice personnel, family members and other relevant parties.

In addition to choosing a health care proxy, some individuals may also decide to write up a living will in which they state their wishes regarding end-of-life care. Living wills raise concerns, however, because these documents attempt to describe our wishes about various medical situations before those situations actually arise, and may end up limiting choices in unreasonable ways. Given the breathtaking pace of medical advances, a person’s decisions today about what care to receive or refuse may not make sense at a later timepoint. In the final analysis, it is impossible and unrealistic to try to cover every medical situation in a living will, and it is preferable to have a proxy, a person we trust, who can interact with the hospital and the health care team, weigh options in real time, and make appropriate decisions for us as we need it.

A new type of living will known as a “POLST” form — a tool for advance planning — also raises concerns. The POLST form (which stands for Physician Orders for Life Sustaining Treatment) is a document that establishes actionable medical orders for a patient’s healthcare. The form is typically filled out with the help of trained “facilitators” — usually not physicians — who ask questions about patients’ health care wishes, and check boxes on the form that correspond to their answers. The facilitators receive training that can lead them to paint a rather biased picture of treatment options for patients, emphasizing potential negative side effects while side-stepping potential benefits or positive outcomes.

POLST forms thus raise several significant moral concerns:

1. The approach encouraged by the use of POLST forms may end up skewed toward options of non-treatment and may encourage premature withdrawal of treatments from patients who can still benefit from them.

2. Filling out a POLST form may preclude a proxy from exercising his or her power to protect the rights of the patient, since the form sets in motion actual medical orders that a medical professional must follow. As a set of standing medical orders, the POLST approach is inflexible. Many POLST forms begin with language like this: “First follow these orders, then contact physician or health care provider.” Straightforwardly following orders created outside of a particular situation may be ill-advised, improper and even harmful to the patient.

3. In some states, the signature of the patient (or his or her proxy) is not required on the POLST. After the form has been filled out, it is typically forwarded to a physician (or in some states to a nurse practitioner or a physician’s assistant) who is expected to sign the form. Thus, in some states, a POLST form could conceivably be placed into a patient’s medical record without the patient’s knowledge or informed consent. In a recent article about POLST forms in the Journal of Palliative Medicine, approximately 95 percent of the POLST forms sampled from Wisconsin were not signed by patients or by their surrogates. Fortunately, in some other states like Louisiana, the patient’s signature or the signature of the proxy is mandatory for the form to go into effect.

The implementation of a POLST form can thus be used to manipulate patients when they are sick and vulnerable, and can even lead to mandated orders for non-treatment in a way that constitutes euthanasia. The POLST template represents a fundamentally flawed approach to end-of-life planning, relying at its core on potentially inappropriate medical orders and dubious approaches to obtaining patient consent.

Notwithstanding the pressure that may be brought to bear on a patient, no one is required to agree to the implementation of a POLST form. Patients are free to decline to answer POLST questions from a facilitator, and should not hesitate to let it be known that they instead plan to rely on their proxy for end-of-life decision making, and intend to discuss their healthcare options uniquely with their attending physician.

 

COMING UP: Vietnamese parish community raises $80,000 for storm relief

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About 800 Vietnamese refugees, immigrants and their relatives gathered on Veterans Day at Queen of Vietnamese Martyrs Catholic Parish event center in Wheat Ridge, raising more than $80,000 for survivors of recent storms in Texas, Florida and central Vietnam.

“We dedicate this event to God, and to Mary,” said co-organizer Viet Hua. “We’ve been praying and asking for help, in God’s way, to glorify him in our effort to help those who suffer.”

It was an evening of food, music, dance and auction goods that sold for thousands more than market value in the spirit of exceeding an ambitious $75,000, one-night fundraising goal. Half the money will go to Gulf Coast recovery, and half will go to Vietnam.

Hua, a member of the parish’s Knights of Columbus chapter, said at least 100 men, women and children volunteered to organize and operate the event.

Denver-area businesses with Catholic and Vietnamese owners, managers and employees minimized overhead with donations of food, beverages, services and auction items.

It touches my heart now to help others – from a place where I can exercise my faith, where I can succeed, and where I can gather with community.”

“This is faith, fellowship and compassion at its finest hour,” said Sang Truong, marketing director of Denver’s Beverage World Specialties, which donated cases of Chilean Paso del Sol wine.

Two major hurricanes wreaked havoc along the Gulf of Mexico this year. As of Veterans Day, 12 tropical storms and typhoons had devastated parts of Vietnam.

Typhoon Damrey struck central Vietnam November 4, destroying nearly 3,500 homes, flooding 138,000 homes, killing 123 people and leaving 395,000 Vietnamese in need of assistance.

The scene is painfully familiar to most who head the 1,800 families that comprise Queen of Vietnamese Martyrs. They endured killer typhoons in the 1960s and ’70s, as communists invaded.

“Communists took over in 1975, and these people came here because they love freedom and they want to practice their faith,” said Pastor Louis Ha Pham, who escaped Vietnam in 1975 with 350 other members of the Congregation of the Mother Co-redemptrix religious community. “They want to use their freedom and faith to help others who suffer and lack the advantages of everything we have here.”

Co-organizer Hua barely survived a typhoon that slammed into his South Vietnamese village when he was a young child in the 1960s.

As water filled the family’s bamboo hut, Hua escaped with his mother and siblings to a neighboring residence. Water soon rushed into that hut, forcing Hua and other occupants to punch through the roof.

“We’re yelling for our lives in the middle of the night,” Hua recalled.

South Vietnamese soldiers pulled them from the water and onto a boat, but the suffering had only begun when Hua and his family reached dry ground in the mountains.

“You have no clothes, no food, and no fresh water. You have nothing,” Hua said. “So it touches my heart now to help others – from a place where I can exercise my faith, where I can succeed, and where I can gather with community.”

Hua escaped Vietnam by himself as a sophomore in high school in 1975. Communists had killed his father. They had threatened him and his family with machine guns.

“I remember they had us lined up, and my grandfather stood there telling them to shoot him,” Hua said. “He lifted up his dirty white t-shirt and said ‘shoot me. Just do it.’ I’m glad they didn’t, because that would have really messed me up as a child.”

Hua built his American life around Our Lady of Vietnamese Martyrs, thanking God each day for liberties the communists took from his homeland.

“I thank God, and I thank Americans for the opportunity to be here with resources to help people back home,” Hua said. “We thank you Americans so much for helping the Vietnamese to migrate here and live free.”

Que Truong, lead organizer of the event, said all Hurricane recovery is hard. It is worse in a dictatorship.

Items were auctioned off as part of a fundraiser held at Queen of Vietnamese Martyrs Parish on Veteran’s Day to help raise money to provide aid to Vietnam, Florida and Texas, which were all recently hit by storms. In total, the parish raised over $80,000 in one evening. (Photos by Dede Laugesen)

“It is terrible over there,” Truong said. “In south Vietnam, we are not free to do anything. There, most people are poor. It’s a different story here, so we are very eager to help.”

Joining the Catholic parishioners were Vietnamese dancers and others from Denver’s Nhu Lia Buddhist Temple. Vietnamese from a Baptist church also participated.

“This is the first time we have all sat down and had dinner together,” said parish Vice President Hung Vu. “Refugees of any religion know how it is to have nothing – to have empty hands and empty stomachs.”

Vu’s father starved to death after a typhoon devastated the family’s village in 1978. Communists ruled the family’s church. Everyone in Vu’s life suffered deprivation of basic needs.

At age 8, Vu fled while working on a fishing boat.

“The boat next to ours planned to escape,” Vu recounted. “They waved me over. In an instant, without a moment to think about it, I jumped out and swam to their boat. They pulled me up and we started sailing out of the China Sea.”

The narrow, 35-foot vessel contained 97 “boat people” crammed together in fetal position. They quickly ran out of food and water, finally obtaining supplies from a passing ship.

“We wanted freedom of religion, and opportunity, and were willing to die trying to get it,” Vu said. “We have suffered. Now, we are so blessed to be here in the United States with all we have. We are so thankful for the veterans who have defended this way of life. This church is my family, and this family is blessed to help those trying to recover in Texas, Florida and Vietnam.”